Easing into MACRA

By Jane Ehrhardt

Published: October 10, 2016

On September 8th, Medicare announced two more ways to participate in the upcoming shift to the Medicare Access and CHIP Reauthorization Act (MACRA). "There are four different payment programs now, since the release of the pick-you-pace model," says Carrie Gulledge, RHIA, director of EHR with MediSys. "They allow providers to test the waters with their toe or jump all in."

Up until now, Centers for Medicare and Medicaid Services (CMS) had devised two programs for paying providers under MACRA: the Alternative Payment Model (APM) -- covering options such as Accountable Care Organizations and Primary Care Medical Homes-- and the Merit-based Incentive Payment System (MIPS). Most Alabama providers will qualify only for MIPS.

Though Medicare may change the dates, right now MIPS providers will report on a variety of metrics for the entire year of 2017. Medicare will use that data to create an overall score for each provider. That score determines the reimbursement or penalty percentage for each provider starting January 1, 2019.

Carrie Gulledge, RHIA

"That's the most common avenue for providers who are accustomed to submitting MU, PQRS and value-based modifiers," says Carrie Gulledge, RHIA, with MediSYS, referring to the various Medicare incentive programs being replaced by MACRA, including Meaningful Use (MU) and Physician Quality Reporting System (PQRS).

For those providers reticent to commit to MIPS, Medicare released two more options. "In a nutshell, the first one says that as long as a provider submits some data to the program within the calendar year of 2017, they can avoid any negative payment adjustments," Gulledge says.

This allows providers to test being part of the program, and engage with their EHR and workflow in generating the required data. "If it works, that provider is in a good position for true reporting beyond 2017," Gulledge says.

Until Medicare publishes the final rule for MIPS -- due in November -- "we won't know if this abbreviated reporting will need to be on one element, one day, one patient or more," Gulledge says. "We only know that it will be just a hair above nothing."

The second option recently released under MIPS takes reporting up a notch from this absolute minimum but remains below the full-year commitment. Providers would report on all the metrics required, but only for a limited amount of time. CMS has yet to define this.

"It could be a 90-day period or ten months," Gulledge says. "It does mean their performance period could begin on any day beyond January 1, 2017, and by doing so, they could still qualify for a small positive payment adjustment."

How exactly these three reporting options will be weighted toward determining the provider's reimbursement rate has yet to be announced. "One would think that if you're reporting successfully for a full year, you should get the most allowed," Gulledge says. But CMS may determine reporting in certain components such as Quality. Or certain measures under those components may count more than others.

This partial reporting diverges from past Medicare incentive programs. "In MU, PQRS and value modifier, you reported all and you got an incentive, or reported nothing and you got penalties," Gulledge says.

The few numbers CMS has released for 2019 include a four percent increase for the top scores and, because the program must be budget neutral, a four percent negative adjustment for providers falling below the benchmark. Percentages will rise two percent every year after, so by 2022 -- the last year a number is mentioned -- best and worst scores will have their reimbursement adjusted positively or negatively by nine percent.

The cut off for being deemed "top" and "low" has not yet been defined. "Right now they're saying probably 25 percent," Gulledge says.

"We do know that if a physician doesn't participate at all, they will get the greatest penalty," Gulledge says. Also, if the amount saved in reduced payments to low performers leaves more in the Medicare coffers than what has been paid to the best performers, the overflow gets doled out to the best performers, up to 12 times the initial percent.

Historically, CMS incentive programs began by only offering a bonus, but then moved to assigning penalties. Those penalties grew for those who chose not to participate. "If you follow the pattern, the loss has gotten greater," Gulledge says. "So from that standpoint, it may not be a good plan to decide not to do it at all. Figure out at least how can you participate in the year after, because at some point that percent reduction is going to get significant."